A midwife is a trained professional with special expertise in supporting women to
maintain a healthy pregnancy birth, offering expert individualized care, education,
counseling and support to a woman and her newborn throughout the childbearing cycle.

A midwife works with each woman and her family to identify their unique physical,
social and emotional needs. When the care required is outside the midwife's scope
of practice or expertise, the woman is referred to other health care providers for
additional consultation or care.

The Midwives Alliance of North America, the North American Registry of Midwives,
the Midwifery Education Accreditation Council and Citizens for Midwifery agreed
on a short definition of what "midwifery care" means. However, just because a person
is a midwife does not guarantee that they provide this kind of care; consumers looking
for a midwife should ask questions to determine if a prospective caregiver will
be able to provide the kind of care they seek.

There are two main categories of midwives in the U.S., nurse-midwives, who are trained
in both nursing and midwifery, and direct entry midwives, who trained as midwives
without being nurses first. Within the category of direct entry midwives are several
subcategories reflecting the varying legal status of these midwives in different
states and the fact that until recently there was no nationally recognized credential
available for direct entry midwives. Direct entry midwives include highly trained
and very competent midwives; however, anyone may call herself a midwife at this
time, and if you are looking for a midwife, it is up to you to find out if the midwife
is qualified and experienced to your satisfaction. If a midwife is a Certified Professional
Midwife (CPM), you are at least assured that she has met specific requirements for
certification (and re-certification every three years).

In 1987 educators, program directors and experienced midwives in the field of direct
entry midwifery decided it was time to begin developing a national credential, the
Certified Professional Midwife (CPM) credential, which is administered through the
North American Registry of Midwives and has rigorous standards for knowledge, skills
and experience.

As of January 2004, there are over 850 CPMs in the United States, Mexico, and Canada.
The nineteen states that license direct-entry midwives to attend births out of the
hospital use the NARM exam or the CPM process as the basis for licensure. States
that are seeking licensure for direct-entry midwives are planning legislation which
requires the CPM credential for licensure.

The North American Registry of Midwives has a free brochure "How to Become a Certified
Professional Midwife (CPM)." You can request a copy or ask for more information
about the CPM by contacting the North American Registry of Midwives at 1-888-84-BIRTH
(eastern time), or by e-mail North
American Registry of Midwives.

Educated in both nursing and midwifery, primarily
in the hospital setting; are "advanced practice nurses."

Must have at least a Bachelors Degree when training
is complete.

Have successfully completed a university-affiliated
nurse-midwifery program accredited by the American College of Nurse-Midwives, and
passed the exam.

Out-of-hospital clinical experience is not required.

Are legal and can be licensed in all states.

Most practice in hospitals and birth centers.

In most states must have some kind of agreement
with a doctor for consultation and referral; practicing without such an agreement
can lead to loss of license.

Certified Midwife (CM)

The Certified Midwife (CM) is a new credential from the ACNM that does not require
a nursing degree but is otherwise similar to the CNM credential. As of 2007, the CM is legally recognized in three states: NY, MA, and NJ, but does not meet existing direct
entry midwife licensing requirements in any other states.

As of 2003, 21 states recognize and regulate direct entry midwives (although for
two of the states, New York and Rhode Island, only the CM credential is acceptable).
Regulation varies from state to state, including licensure, certification, registration
and documentation. Only 9 states and the District of Columbia actually prohibit
the practice of direct entry midwives, but in 5 more states licensure is required
but unavailable. In the remaining states direct entry midwives practice without
any kind of state regulation, and in a few the legal status in not entirely clear.
So, direct entry midwives are practicing essentially legally in about 34 states,
but are considered unlawful or illegal in 14 states. However, these figures are
subject to change as new legislation is enacted or new legal opinions are established
that can change status in the a-legal states where direct entry midwives are neither
specifically regulated nor specifically prohibited.

You need to consider how much education you want, what setting(s) you want to practice
in, what state(s) you might want to live and practice in, and what income level
is important to you, because these factors differ pretty much along the lines of
the two categories of midwives. We recommend that you interview several different
kinds of midwives with different practices before making a decision.

Setting: Are you interested in practicing in the hospital
setting or primarily out-of-hospital?

CNMs practice mainly in medical settings and in almost every state are required
to have some kind of agreement with a physician in order to practice (which means
your work situation is dependent on the physician letting you practice, even though
you may both be competing for the same clients/patients). However, since CNMs are
trained as advanced practice nurses, and are under "doctor supervision" they can
"do" more in terms of using drugs for pain relief, some kinds of well-woman care,
even in some instances assisting at cesarean births, depending on the state and
the physician they work with/for. Fewer than 2% of CNMs attend home births; in some
states quite a few CNMs work in birth centers.

Direct entry midwives also usually are able to spend much more time with women during
prenatal care visits and usually stay with the birthing woman throughout labor and
delivery. While some CNMs are able to practice like direct entry midwives, most
are limited by hospital and doctor policies, and busy practices, sometimes mandated
by HMOs, may mean the CNM just comes in to catch the baby and is not able to provide
the continuous hands-on care we associate with the Midwives Model of Care.

In contrast, almost all direct entry midwives attend births in homes or in free-standing
birth centers, although a very few licensed midwives are now getting hospital privileges
or hospital employment. What direct entry midwives are legally able to do in terms
of drugs and minor interventions depends on each individual state law. On the other
hand, direct entry midwives are generally much freer to use alternative methods
including homeopathic, herbs, massage and imagery for pain relief and encouragement
of labor

Education and accredited programs

In terms of education, while in the past a baccalaureate degree was not required
to become a CNM, the trend is toward requiring this degree, and moving toward requiring
a Masters Degree. For example, even now to practice as a CNM in Oregon, you must
have a Bachelors Degree, even if you already got your CNM credential without that
degree. The American
College of Nurse Midwives has made it quite clear that they are moving toward
all their midwife programs eventually requiring a Masters; they are already phasing
out programs that did not require a Bachelors.

The Certified Professional
Midwife credential, by contrast, is not degree-oriented or program-based. A
college degree is not required, and the emphasis is on what you know rather than
how you learned it. The rigorous credentialing process validates that you have all
the knowledge, skills and experience necessary to practice as an entry level midwife,
as determined by a comprehensive task analysis involving hundreds of midwives encompassing
the full range of midwifery from CNMs to apprentice-trained rural midwives. The
CPM credential is available to any kind of midwife, including CNMs, who meet the
requirements.

Direct entry midwifery programs increasingly are being accredited by the Midwifery Education Accreditation Council (MEAC)
a federally recognized accrediting agency, which as of January 2004 has accredited
or pre-accredited nine programs located in 11 states (Arkansas, Florida, Maine,
New Mexico, Oregon, Texas, Utah, Vermont and Washington). All include a structured
curriculum, mostly in formal classroom settings, as well as apprenticeship elements
("one on one learning by experience with a mentor having a significant relationship
with a student"). Pre-accredited programs have met all requirements for accreditation
except that they do not yet have the required number of graduates who are certified
or licensed. For more information about direct entry midwifery education programs,
especially those accredited by MEAC, email
MEAC or call 928-214-0997.

At this time you can become a midwife and qualify for CPM certification without
completing a MEAC-accredited program. Ask actively practicing direct entry midwives
for their suggestions on how to go about becoming a midwife. For example, many start
out being childbirth educators or doulas first, and there is also a lot of "book
learning" you can do even before you are in a position to actually apprentice or
go to a program.

Some midwives end up with combined training - they either started out as direct
entry midwives, but at some point went back to school to become a CNM in order to
practice legally, or for income or job security, or to be able to serve more and
higher risk women, or for some other reason. So they are CNMs but retain their direct
entry midwife orientation. Alternatively, other women become CNMs, but wanting to
acquire a less medicalized fear-based approach to birth, subsequently work with
direct entry midwives in an apprenticeship-type arrangement.

Income

Income for a CNM ranges from around $30,000 to $80,000, depending on where she practices
and what she does. The higher income brackets include CNMs with management positions
in urban hospitals, and CNMs in teaching positions in nurse-midwifery programs.
For DEMs the income range generally is lower, and depends on factors like the location
(urban or rural), which state (legal or not, insurance coverage or not), and how
many births a DEM does in a given period of time.

Another consideration is whether you want to work for someone else or have your
own practice (ie, your own business). Almost all direct entry midwives have their
own businesses; the majority of nurse-midwives are employees of hospitals or doctors
or birth centers and even those in private practice must of necessity be closely
aligned with one or more doctor practices - relatively few are entrepreneurs in
the way that most direct entry midwives are. Being an employee often means regular
hours, vacations and employee benefits. Being self-employed can mean longer and
more unpredictable hours, but also more flexibility. Either way is likely to affect
the kind of care you are able to offer to your clients.

Legal Status

On the MANA website is a
Legal Status Chart showing the legal status of direct entry midwives in every
state. Direct entry midwives practice in all states, but are vulnerable to investigation
and arrest in those states with no functional regulatory law.

While CNMs are legal in all states, the need for doctor collaboration or practice
agreements means most CNMs are vulnerable to the ability of doctors to terminate
or refuse to participate in practice agreements with midwives, and their ability
to influence hospitals to refuse privileges to midwives (who in many cases are competing
for the same clients as the doctors are).

CfM is a national, grassroots organization of midwifery advocates dedicated to promoting
the Midwives Model of Care so that it becomes universally available and recognized
as the optimal kind of care for childbirth.